Higher Risk of Psychosis Among Refugees

A study published in the British Medical Journal has found that refugees in Sweden have a substantially higher risk of schizophrenia and nonaffective psychotic disorders than other migrants. We spoke with the study’s lead author, Anna-Clara Hollander of Sweden’s Karolinska Institute.

A newly published study, conducted by the Karolinska Institute and University College London (UCL), analyzed health data from more than 1.3 million people in Sweden. It found that refugees are on average 66 percent more likely than other migrants to develop nonaffective psychotic disorders such as schizophrenia.

The study drew on refugee records dating back to 1998. Although Sweden’s reputation as one of the most welcoming countries to refugees took a hit in January – when the government announced it would deport 60,000 to 80,000 rejected asylum seekers – the study could shape the way refugees access mental health services in Scandinavia and other parts of Europe. We spoke with the report’s lead author to learn more.

Refugees Deeply: Why did you decide to launch the study?

Anna-Clara Hollander: On a per capita basis, Sweden has granted more refugee applications than any other high-income country and in 2011, refugees made up 12 percent of the country’s immigrant population. It’s been known for some time that migrants in general have a higher risk of schizophrenia and other kinds of nonaffective psychosis. In the beginning, the studies weren’t very big, but it’s now something that has been tested several times. It’s been seen everywhere, from Norway to the U.S., and from the Caribbean to the U.K. Historically, one hypothesis was that nonaffective psychoses can be triggered by traumatic experiences. If true, then migrants and refugees would of course have an increased risk. We decided to test it.

Refugees Deeply: What were the key findings?

Anna-Clara Hollander: As seen before, migrants in Sweden have an increased risk of nonaffective psychosis including schizophrenia. But we found that refugees have an even higher risk, and were on average 66 percent more likely to develop nonaffective psychosis. The risk varied by gender and country of origin.

We decided to differentiate between migrants and refugees because we imagined that refugees would have experienced more traumatic events. Our data cannot pinpoint where the trauma may have occurred, but we suspect that it was both in the countries of origin and during the journey to freedom. Once refugees and migrants actually arrive in Sweden, the experiences of refugees and migrants are often similar. The difference between the two groups is during the journey to Sweden.

Refugees Deeply: The study showed that the risk is higher for all of those from sub-Saharan Africa, with a case incidence of 269 per 100,000 non-refugee migrants. Why do you think this is so?

Anna-Clara Hollander: It’s in line with findings from other studies, but it’s very difficult to say why this is so. It could be linked to other kinds of trauma experienced in their home countries, or it could be due to greater discrimination once they arrive in Sweden. A study from Holland showed that discrimination is a risk factor for nonaffective psychosis. It could be tied to more difficult experiences in Sweden; social support, or lack of it, could be a factor. It would be interesting to study the impact on social support networks once these migrants and refugees arrive in Sweden or other destination countries.

Refugees Deeply: The study was conducted using data that runs up to 2011. What are its implications for the current refugee crisis?

Anna-Clara Hollander: I don’t think there’s a reason to believe that rates would be significantly different now, because the refugees and migrants come from the same areas as before. However, because of the current refugee crisis, it’s very important to highlight the fact that migrants and refugees are vulnerable to certain health issues, including severe and sometimes chronic nonaffective psychosis. Since we published the study, many clinicians have said that the results mirror the clinical reality.

It’s very important for people with nonaffective psychosis to get treatment as quickly as possible, at an early stage. For migrants and refugees, there are sometimes barriers to accessing healthcare, so it’s particularly important that people know what to look for. It’s important for clinicians to ask patients about their migration history, and to recognize that a refugee background is a risk factor for schizophrenia and other psychoses. Clinicians in high-income countries should be aware of this, and they should intervene at an early stage if there are symptoms.

Refugees Deeply: What are the risk factors for developing schizophrenia and other nonaffective psychoses in general? Is there always an underlying genetic factor?

Anna-Clara Hollander: There is a very strong genetic component. Studies have shown this for a very long time. But more and more studies show that triggers can activate a genetic predisposition to nonaffective psychosis. Many people do carry the genetic risk factor, but traumatic experiences may spark the actual illness.

Refugees Deeply: Are there any limitations on refugees and migrants in Sweden accessing health services? Have you documented any stigma around mental health among refugees and migrants?

Anna-Clara Hollander: Sweden has universal, free health coverage for everybody with a permanent residence permit. We’ve been looking only at people who have this access. Asylum seekers in Sweden have restricted access to healthcare, but we didn’t include these people in the study because we wanted to focus on those who did have access.

We couldn’t measure stigma as part of the study. But we do think there is an under-usage of mental health services in general among refugees and migrants.

Refugees Deeply: Lastly, do you have any plans to build on this study?

Anna-Clara Hollander: I’d be very interested to explore any links between nonaffective psychosis and discrimination. The study would be interesting to do in other countries as well, although I think that the results would be similar for other high-income countries that are destinations for migrants and refugees.

Top image: A refugee looks out while sitting in a bus at the Greek-Macedonian border, while she and others wait to be permitted by Greek policemen to cross the border by foot. (AP Photo/Muhammed Muheisen)

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